Egg Allergy Is No Longer a Contraindication for the Flu Vaccine

The following is a blog post from KFA's Medical Advisory Team from 2012:

2012 UPDATE ON EGG ALLERGY AND THE FLU VACCINE

by Matthew J. Greenhawt, MD, MBA, MSc

Much has changed regarding the perceived safety of influenza vaccine in egg allergic individuals. The Centers for Disease Control (CDC) no longer considers egg allergy a contraindication to receiving an influenza vaccine. This is based on several research studies conducted in recent years, which conclusively show the injectable influenza vaccine is safe for children with egg allergy.

The American Academy of Allergy, Asthma, and Immunology (AAAAI) and the American College of Allergy, Asthma, and Immunology (ACAAI) have updated the national practice parameter on this topic twice in the past 3 years, most recently this past summer. The Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control updated its recommendations in August of 2012. Though the AAAAI/ACAAI and the ACIP recommendations differ slightly, the main points are largely the same:

Skin testing to the vaccine is no longer advised, and is not necessary to receive the vaccine. Several studies have shown that this does not help predict who will develop a reaction to the vaccine, even when the skin tests are positive.

While either a single dose or a two-step graded challenge are acceptable ways to vaccinate egg allergic individuals, a single dose has been shown to be safe even in children with a history of anaphylaxis to egg, Therefore, the use of two-step graded challenges are not necessary, though many providers likely will continue to use this method.

The amount of egg (ovalbumin) in influenza vaccine is low and has been for the past several years. A 1997 study did note that vaccine ovalbumin content below 1.2 micrograms/mL was well tolerated in egg allergic individuals, and has since served as a “de facto” safe level. Furthermore, this “safe” level was not a designed outcome of the study, and represented what the level of ovalbumin in the vaccine happened to be in the lots used in the study. Ovalbumin in influenza vaccine has never directly been attributed to causing reactions in egg allergic individuals. There is recent data that has shown higher ovalbumin levels were well tolerated. However, all presently marketed injectable influenza vaccine for use in the US contain less than 1.2 micrograms/mL, and this argument is no longer of clinical relevance. The CDC has published this information in August of the past two years. Though Sanofi Pasteur’s Fluzone was not included in those publications, through personal communication with Sanofi, the company has verified that Fluzone’s ovalbumin content is under 1mcg/mL

There is now data supporting that ALL egg allergic patients can safely receive their influenza vaccine, regardless of how severe their egg allergy was in the past. This includes children with anaphylaxis to egg. Moreover, a very recent study has shown that children with severe egg allergy can receive their influenza vaccine as a single dose, as opposed to a two-step graded challenge.

The latest guidelines from the CDC were updated in August 2012 and were unchanged from August 2011. These recommend that children with a history of developing only hives after egg ingestion can receive the vaccine at the pediatrician's office. If the egg reaction was more severe, these children can still get the vaccine, but at an allergist's office.

Some additional important points:

The safety of the intranasal spray form of the vaccine, known as Flumist, in egg allergic children is still being evaluated. The CDC recommends that egg allergic individuals only receive the injectable vaccine.

Children with an egg allergy can receive the injectable flu vaccine, but it needs to be done in a pediatrician’s office or an allergist’s office (depending on the egg allergy severity) rather than in a minute clinic, health department clinic or pharmacy.

If your child has a history of reaction to the vaccine itself, this is a different scenario than someone with a history of egg allergy but has not ever reacted to the flu vaccine. Children who have reacted to the actual vaccine should be evaluated by a board certified allergist to determine if it is safe for them to receive the vaccine in the future.

The package inserts for the influenza vaccine will still have the original wording regarding contraindications with egg allergy, even though the CDC recommendations now state it’s safe to administer to children with an egg allergy in a pediatrician’s or allergist’s office.

In conclusion, the thinking on the topic of the safety of the administration of the influenza vaccine for egg allergic individuals has changed significantly. Importantly, egg allergic individuals wanting to receive injectable influenza vaccine can do so. The vaccine is no longer contraindicated because of egg allergy, and the vaccine is safe even if there has been a severe past reaction to egg. Either your pediatrician or your allergist (depending on the egg allergy severity) can provide the flu vaccine.

Matthew Greenhawt, MD, MBA, MSc, is assistant professor, Department of Internal Medicine, Division of Allergy & Clinical Immunology and the University of Michigan Food Allergy Center, University of Michigan Medical School and University of Michigan Health System Ann Arbor, Michigan. He is a member of KFA’s Medical Advisory Team. He is co-author of the 2011 special practice parameter update on the safety of influenza vaccine in egg allergic individuals, and co-author of the 2012 practice parameter on adverse reactions to vaccines.

My son is extremely allergic to egg and gelatin when used in vaccines. When he was 4 years old, he had a severe reaction to his shots. Two months later, he received the flu vaccine (h1n1 as well as reg flu) and had the same reaction within 15 minutes. We saw an allergist who did a skin test proving it was the gelatin and egg. He has heart defects so we tried to do the multi-step flu shot, and he had an immediate reaction. Hives, rapid breathing and pulse, burning inside, lethargy. When he eats gelatin he gets itchy ears, but in a vaccine (MMR) he is in severe trouble. So, long story short, we must avoid all vaccines with these ingredients.

I'm sorry to hear that your children had reactions to the flu vaccine. Other components of the flu vaccine like gelatin can cause allergic reactions in some children. Your allergist can sort that out. And of course, if your child did have a reaction to the vaccine, as the article said, that is a different scenario and you'd have to follow up with an allergist for as well.

If it's so safe, why is it recommended that it be given in an allergist's/pediatrician's office? Also, why wouldn't the mist be safe? It sounds like good news but I think I'll still give it a few years for my son in case they change their minds again...

Belgiumite - the flu mist contains live virus; it's a different type of vaccine. The studies the updated recommendations were made on were based on the injectable form of the vaccine.

dvk - as a consumer, you make the decisions for your child. However, these guidelines are what the CDC have adopted based on the clinical evidence. Other parents will want this information to initiate a conversation about the flu vaccine with their child's allergist, and that is why we've provided it.

Our allergist says that they have never had an egg-allergic child react iwith ana to the flu vaccine. They give it in the office to be on the safe side (they have all the rescue meds in the unlikely event there should be a reaction). My son has had it the past three years without any issues whatsoever.

My son is ana to trace amounts of egg--he has reacted to cross-contamination. He also has asthma and if he gets the flu, he is at increased risk of hospitalization or even death. We have weighed the pros and cons of the flu vaccine and the dangers of getting the flu and have decided that it is worth it. We would only give it in a controlled and observed environment however.

If my son did not have asthma, I might not feel that it was worth the risk. In addition, if he reacted to a previous flu vaccine , we would not give it either. There are a lot of factors that go into something like this. There is no "one-size-fits-all" for this. It used to be that people would automatically not give the flu shot if there was an egg allergy.

The fact of the matter is that it is safer than previously thought, but it is still important to go by past history and consider all of the risk factors with your doctor before coming to a hard and fast decision.

My daughter is allergic to eggs and has never passed a flu vaccine skin test. This year is the first time she's ever had a flu vaccine. She developed a rash (not common with her) several hours later. While this may be a reaction to something else, I'm reluctant to have her vaccinated again unless she outgrows the allergy.Her doctor dismissed my concerns completely.We're looking for a new allergist.

My dd received the flu shot for the first time this year. She has had severe reactions to miniscule amounts of egg. But she had no reaction to the flu shot! It was quite a relief. Her allergist, who sees many kids with severe egg allergy, said at most he's seen a few kids with minor reactions. The vast majority have not reacted at all.

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